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Objective Diabetes mellitus (DM) has been known to compromise tuberculosis (TB) treatment outcomes. Association data are limited for early hyperglycaemia detection and TB treatment outcomes. Thus, we assessed treatment outcomes including time to sputum conversion and death in TB participants with or without hyperglycaemia. Methods A prospective cohort study recruited TB participants receiving anti-TB treatment at health facilities in Tanzania between October 2019 and September 2020. Hyperglycaemia was defined as having pre-existing DM or pre-treatment random blood glucose of >= 7.8 mmol/L, in combination categorised as impaired glucose regulation (IGR). Those with IGR were further screened for hyperglycaemia severity using glycated haemoglobin. In case of unknown status, participants were tested for HIV. Time to death was determined at 6 months of TB treatment. Results Of 1344 participants, 187 (13.9%) had IGR, of whom 44 (23.5%) were HIV co-infected. Overall treatment success was 1206 (89.7%), and was similar among participants with or without IGR (p > 0.05). Time to death for participants with and without IGR was 18 versus 28 days (p = 0.870), respectively. Age >= 40 years (p = 0.038), bacteriological positive (p = 0.039), HIV (p = 0.009), or recurrent TB (p = 0.017) predicted death or treatment success during TB treatment in adjusted multivariable models. Conclusion IGR did not influence clinical outcomes in TB patients with or without IGR in a programme of early IGR diagnosis and integration TB, HIV and DM care. Early detection and co-management of multi-morbidities among people diagnosed with TB may reduce likelihood of poor treatment outcomes in a programmatic setting.

BACKGROUND From a diabetes management perspective, informal care has proven at least as important as care from health professionals when targeting poorly controlled diabetes. The objective of this study was to identify determinants associated with unmet needs for informal support among people with type-2 diabetes in rural communities of Vietnam. METHODS A cross-sectional survey was conducted from December 2018 to February 2019 in a rural area of northern Vietnam. From 2 districts in Thai Binh Province, Vietnam, 806 people with type-2 diabetes participated in a survey designed to assess who were their most important informal caregivers (ICGs) and to measure the association between demographic and socio-economic predictors and unmet needs of informal support of relevance for diabetes self-care using bivariate and multivariate analyses. RESULTS The spouse was reported as the most important ICG (62.9%) followed by a daughter or son (28.4%). 32.0% of the people with type-2 diabetes reported at least one type of unmet need for informal support. The most commonly reported unmet needs of informal care were: transport to health facilities and company when seeking formal care (20.5%), financial support related to costs of diabetes self-management (18.5%), and reminders to engage in physical exercise (14.5%). People living alone reported the highest odds ratio (OR) for unmet need of informal care (OR=4.41; CI95%: 2.19-8.88), followed by those being poor as compared to being wealthy (OR=3.79; CI95%: 1.25-11.52) and those being unemployed as compared to being retired (OR=2.85; CI95%: 1.61-5.05). CONCLUSIONS Almost one-third of people with type-2 diabetes reported at least one type of unmet need for informal care. These findings provide a basis for development of new modalities for strengthening support provided by ICGs in rural communities in Vietnam and in other low- and middle-income countries.

Summary: To end the international crisis of preventable deaths in low-income and middle-income countries, evidence-informed and cost-efficient health care is urgently needed, and contextualised clinical practice guidelines are pivotal. However, as exposed by indirect consequences of poorly adapted COVID-19 guidelines, fundamental gaps continue to be reported between international recommendations and realistic best practice. To address this long-standing injustice of leaving health providers without useful guidance, we draw on examples from maternal health and the COVID-19 pandemic. We propose a framework for how global guideline developers can more effectively stratify recommendations for low-resource settings and account for predictable contextual barriers of implementation (eg, human resources) as well as gains and losses (eg, cost-efficiency). Such development of more realistic clinical practice guidelines at the global level will pave the way for simpler and achievable adaptation at local levels. We also urge the development and adaptation of high-quality clinical practice guidelines at national and subnational levels in low-income and middle-income countries through co-creation with end-users, and we encourage global sharing of these experiences.

IntroductionFetal malaria exposure may lead to intrauterine growth restriction and increase the risk of developing diabetes and cardiovascular diseases in adulthood. We investigated the extent to which fetal peripheral and placental malaria exposure impacts insulin sensitivity and secretion, body composition and cardiometabolic health 20 years after in utero malaria exposure.Research design and methodsWe traced 101 men and women in Muheza district, Tanga region whose mothers participated in a malaria chemosuppression during a pregnancy study in 1989–1992. All potential participants were screened for malaria, hepatitis B and HIV to ascertain study eligibility. Seventy-six individuals (44 men, 32 women) were included in this cohort study. The participants underwent a thorough clinical examination including anthropometric measurements, ultrasound scanning for abdominal fat distribution, blood pressure, 75 g oral glucose tolerance test, an intravenous glucose tolerance test followed by a hyperinsulinemic euglycemic clamp and a submaximal exercise test.ResultsOffspring exposed to placental malaria during pregnancy had significantly higher 30-minute plasma post-glucose load levels, but no significant difference in peripheral insulin resistance, insulin secretion or other cardiometabolic traits compared with non-exposed individuals.ConclusionsUsing the state-of-the-art euglycemic clamp technique, we were unable to prove our a priori primary hypothesis of peripheral insulin resistance in young adult offspring of pregnancies affected by malaria. However, the subtle elevations of plasma glucose might represent an early risk marker for later development of type 2 diabetes if combined with aging and a more obesogenic living environment.

Introduction: there is scarce evidence of the effects of obesity and gestational weight- gain (GWG) on hemoglobin (Hb) levels in pregnancy. Little is known about the implications in offspring when pregnant mothers present with both at delivery. Aim: to identify if pre-pregnancy body mass index (BMI) and GWG are associated with Hb levels at pregnancy third trimester; and identify if the BMI status plus anemia at delivery could influence offspring anthropometry. Methods: in a sub-sample of pregnant women (n = 108) and their offspring (n = 63) from a Mexican birth cohort, information from medical files and questionnaires were used to obtain pre-pregnancy BMI (categorized as normal, overweight, and obese), GWG, and Hb during pregnancy; at delivery and postpartum anthropometric measures were obtained for offspring. Adjusted regression models predicted Hb levels according to pre-pregnancy BMI and GWG; offspring growth trajectories from birth to 3 months old were compared according to mother´s BMI status and anemia combinations at delivery. Results: pre-pregnancy normal (N), overweight (OV), and obesity (OB) were present in 48 %, 40 %, and 12 % of the participants, respectively. Anemia was detected in 22.8 % of the participants at third trimester. Hb levels in the third trimester were significantly lower in those with pre-pregnancy OB-BMI and excessive GWG (12.1 g/dL, 95 % CI: 10.7-13.5) compared to those with pre-pregnancy OB-BMI and insufficient GWG (13.3g/dL, 95 %CI: 11.9-14.8) (p = 0.04). At delivery, 11 % presented with OB-BMI and anemia. Women with OB-BMI and normal Hb levels had children with higher scores in Weight-for-Length-Z score and triceps skinfold. Conclusion: among OB women, excessive GWG was associated with having lower Hb levels in the third trimester. Newborns had higher scores in growth patterns related to adiposity from birth to 3 months old if mothers had normal Hb levels and OB.Introducción: existe escasa evidencia de los efectos de obesidad y ganancia de peso gestacional (GPG) y niveles de hemoglobina (Hb) durante el embarazo. Poco se conoce sobre las implicaciones en la descendencia cuando las embarazadas presentan ambos en el momento del parto. Objetivos: identificar si el índice de masa corporal (IMC) previo al embarazo y el GPG están asociados con los niveles de Hb en el tercer trimestre del embarazo; e identificar si el IMC más la anemia en el momento del parto podrían influir en la antropometría de la descendencia. Metodología: se utilizó información de expedientes médicos y cuestionarios para obtener el IMC antes del embarazo (categorizado como normal, con sobrepeso y obesidad), GPG y Hb durante el embarazo; en el momento del parto y posparto se obtuvieron medidas antropométricas para la descendencia de una submuestra de mujeres embarazadas (n = 108) y su descendencia (n = 63) de una cohorte mexicana. Los modelos de regresión ajustados predijeron los niveles de Hb según IMC y GPG antes del embarazo; se compararon las trayectorias de crecimiento de la descendencia desde el nacimiento hasta los 3 meses de edad según el estado de IMC de la madre y las combinaciones de anemia en el momento del parto. Resultados: peso preembarazo normal (N), sobrepeso (SP) y obesidad (OB) estuvieron presentes en 48 %, 40 % y 12 % de las participantes, respectivamente. Se diagnosticó anemia en el 22,8 % de las participantes en el tercer trimestre. Los niveles de Hb en el tercer trimestre fueron significativamente más bajos en aquellas con IMC-OB antes del embarazo y GPG excesivo (12,1 g/dL, IC del 95 %: 10,7-13,5) en comparación con aquellas con IMC-OB antes del embarazo y GPG insuficiente (13,3 g/dl, IC del 95 %: 11,9-14,8) (p = 0,04). Al momento del parto, el 11 % presentó OB-BMI y anemia. Las mujeres con OB-BMI y niveles normales de Hb tenían hijos con puntuaciones más altas en puntuación Z de peso para longitud y pliegue cutáneo del tríceps. Conclusión: la GPG excesiva entre las mujeres OB se asoció con niveles más bajos de Hb en el tercer trimestre. Los recién nacidos tenían puntajes más altos en los patrones de crecimiento relacionados con la adiposidad desde el nacimiento hasta los 3 meses de edad si las madres tenían niveles normales de Hb y OB.

Objectives: Informal caregivers' (ICGs') knowledge has substantial influence on the quality of caregiving. This study aims to identify caregivers’ perceived knowledge status and analyse associations between their characteristics and perceived knowledge on how to care for individuals with type-2 diabetes (T2D). Study design: Cross-sectional study. Methods: Data were collected using a face-to-face survey with ICGs and perceived knowledge was evaluated on the 5-point Likert scale (ranging from 0 to 4). Results: Between April and July 2019, 1238 eligible ICGs were enrolled in the study. The mean age of participants was 48.3 years, about half (48.8%) were males and the majority (83.3%) were spouses or children of the person they cared for. ICGs mean knowledge score on overall activities was 2.48 (SD = 0.90); the highest score was seen for diet preparation (2.74 ± 0.85) and lowest for foot care (1.76 ± 1.45). Multivariate analyses showed that the following ICG characteristics were significantly more likely to result in a low level of T2D-related knowledge (mean score ≤2): age

OBJECTIVES: The agro-pastoralist Maasai of East Africa are highly physically active, but their aerobic fitness has so far only been estimated using heart rate (HR) response to submaximal exercise and not directly measured. Thus, we aimed to measure aerobic fitness directly using respiratory gas analysis in a group of Maasai, and habitual physical activity energy expenditure (PAEE) as explanatory variable. METHODS: In total, 21 (10 rural, 11 semi-urban) of 30 volunteering Tanzanian Maasai men were eligible to participate. Respiratory gas exchange was measured during a graded exercise test until exhaustion on a stationary bicycle to determine aerobic fitness. Maximal effort criteria were at least two of the following 1) levelling off, 2) respiratory exchange ratio (RER) >1.10, and 3) maximum HR within 10 bpm of age-estimated maximum HR. Habitual physical activity energy expenditure (PAEE) was estimated using combined accelerometry and HR monitoring. Anthropometry, biochemistry, blood pressure, resting HR, and dietary intake information were collected for background information. RESULTS: Mean age was 43.2 (range 26-60) years, and hemoglobin was higher in the rural vs. semi-urban Maasai (16.9 vs. 15.4 g/dL, p=0.02). Mean aerobic fitness (34.4 vs. 33.3 ml · min(-1) · kg(-1), p=0.79), and mean PAEE (58.5 vs. 52.9 kJ · day(-1) · kg(-1), p=0.64) were similar in rural and urban Maasai, respectively. CONCLUSIONS: Aerobic fitness was low to moderate in male rural and semi-urban Maasai. This may be explained by relatively low PAEE in comparison to previous objectively measured activity levels in Maasai, which indicates recent lifestyle changes.

Background Diabetes-related distress (DRD) refers to negative emotional and affective experiences from daily demands of living with diabetes. People who received social support seem less likely to experience DRD. The prevalence of T2D in Vietnam is rapidly increasing. Yet, DRD and its association with social support have not been investigated. This study investigates DRD and how it is associated with unmet needs for social support in people with T2D in Thai Binh Province, Vietnam. Methods A total of 806 people, age ≥ 40 years, treated for T2D at primary hospitals in Thai Binh Province, Vietnam, completed a questionnaire-based cross-sectional survey. DRD was self-reported, based on the Problem Areas In Diabetes scale 5 (PAID5). We assessed 6 types of unmet needs for social support from family/friends/community including: (i) Transport and company when visiting health facilities; (ii) Reminders to take medication; (iii) Purchase and preparation of food; (iv) Reminders to engage in physical exercise; (v) Emotional support; and (vi) Financial support. Multivariable logistic regression was used to model DRD as an outcome of each type of unmet need for social support, and as an outcome of the number of unmet needs for social support, adjusted for three sets of covariates. Results In this study, 50.0% of people with T2D experienced DRD. Odds for DRD were higher among those who had any unmet need for social support. After adjustment for household economic status, only unmet needs for emotional and financial support were associated with higher odds ratios of DRD (OR = 2.59, CI95%: 1.19–5.63 and OR = 1.63, CI95%: 1.10–2.40, respectively). People who had ≥2 type of unmet need were not a higher risk of experiencing DRD as compared to those with no unmet need. Conclusions Half of the people with T2D experienced DRD. The results suggest that having enough finances may decrease most needs for social support with the exception of emotional support. Thus, social support to financial and emotional of diabetes aspects may contribute to prevent or reverse DRD.

Introduction: Anemia during pregnancy may compromise fetal and newborn's health, however, little is known about how and when the fetoplacental vascularization is most vulnerable to anemia. Methods: Using systematic and isotropic uniform random sampling, placental samples were collected from 189 placentas in a cohort study of Tanzanian women whose hemoglobin concentration was measured throughout pregnancy. Fetoplacental vessels and villi were defined as exerting either a transport or diffusion function. The vascularization patterns for transport and diffusion vessels and villi were assessed by stereology. Blood vessel length, surface area and diffusion distance as well as placental villi volume were calculated. Results: Anemia from a gestational age of 23 weeks was significantly associated with increased fetoplacental vascularization in vessels and villi compared to women who were non-anemic throughout pregnancy. Transport surface vessel area: 0.31 m 2 [95% CI: 0.18–0.55], P = 0.01; Transport villi volume 19.8 cm 3 [95% CI: 6.37–33.2], P = 0.004, Transport vessel diameter 7.23 μm [95% CI: 1.23–13.3], P = 0.02. Diffusion vessel surface: 3.23 m 2 [95% CI: 1.55–4.91], P < 0.001 and diffusion villi volume: 29.8 cm 3 [95% CI: 10.0–49.5], P = 0.003). Finally, all the measured transport vessel and villi significantly parameters and diffusion vessel surface, vessel diameter and diffusion distance were associated with birth weight. Discussion: Increased fetoplacental vascularization related to anemia from a gestational age of 23 weeks in pregnancy together with the association between fetoplacental vascularity and birth weight suggest that the timing of anemia determines the effect on fetoplacental vascularization and underlines the clinical relevance for proper development of fetoplacental vasculature.

IntroductionMost sub-Saharan African countries endure a high burden of communicable infections but also face a rise of non-communicable diseases (NCDs). Interventions targeting particular epidemics are often executed within vertical programmes. We establish an Adaptive Diseases control Expert Programme in Tanzania (ADEPT) model with three domains; stepwise training approach, integration of communicable and NCDs and a learning system. The model aims to shift traditional vertical programmes to an adaptive diseases management approach through integrating communicable and NCDs using the tuberculosis (TB) and diabetes mellitus (DM) dual epidemic as a case study. We aim to describe the ADEPT protocol with underpinned implementation and operational research on TB/DM.Methods and analysisThe model implement a collaborative TB and DM services protocol as endorsed by WHO in Tanzania. Evaluation of the process and outcomes will follow the logic framework. A mixed research design with both qualitative and quantitative approaches will be used in applied research action. Anticipated implementation research outcomes include at the health facilities level for organising TB/DM services, pathways of patients with TB/DM seeking care in different health facilities, factors in service delivery that need deimplementation and the ADEPT model implementation feasibility, acceptability and fidelity. Expected operational research outcomes include additional identified patients with dual TB/DM, the prevalence of comorbidities like hypertension in patients with TB/DM and final treatment outcomes of TB/DM including treatment-related complications. Findings will inform the future policies and practices for integrating communicable and NCDs services.Ethics and disseminationEthical approval was granted by The National Research Health Ethical Committee (Ref-No. NIMR/HQ/R.8a/Vol.IX/2988) and the implementation endorsed by the government authorities. Findings will be proactively disseminated through multiple mechanisms including peer-reviewed journals, and engagement with various stakeholders’ example in conferences and social media.

Background: Diabetes-related distress (DRD) in people with type 2 diabetes (T2D) is associated with reduced quality of life. Lower levels of DRD were found in people who received informal support. The prevalence of T2D in Vietnam is rapidly increasing. Yet, the prevalence of DRD and its association with informal social support have not been investigated. The present investigate the prevalence of DRD and its association with unmet needs for informal support in people with T2D in Vietnam. Methods: A total of 806 people, age ³40 years, diagnosed with T2D in Thai Binh, Vietnam, completed a questionnaire-based cross-sectional survey. DRD was self-reported, based on the Problem Areas In Diabetes scale 5 (PAID 5). We assessed 6 types of unmet needs for informal support from family/friends/community including: (i) Transport and company when visiting health facilities; (ii) Reminders to take medication; (iii) Purchase and preparation of food; (iv) Reminders to engage in physical exercise; (v) Emotional support; and (vi) Financial support. Multivariable logistic regression was used to model DRD as an outcome of each type of unmet need for informal support, and as an outcome of the number of unmet needs for informal support, adjusted for three sets of covariates. Results: The prevalence of DRD in people with T2D was 50.0%. Odds for DRD were higher among those who had unmet needs for emotional support and financial support as compared to those with met needs (OR=2.59, CI95%: 1.19-5.63 and OR= 1.63, CI95%: 1.10 -2.40, respectively). People who had more than one type of unmet need was not a higher risk of DRD as compared to those with only one type of unmet need. Conclusions: Half of the people with T2D had DRD. DRD was associated with unmet needs for emotional and financial support. The findings suggest that in order to prevent or reverse DRD, family members and others providing informal support should be included in health programs and interventions targeting people with T2D in Vietnam and similar settings.

Mutations in the Plasmodium falciparum genes Pfdhfr and Pfdhps, particularly the sextuple mutant haplotype threatens the antimalarial effectiveness of sulfadoxine-pyrimethamine (SP) as intermittent preventive treatment during pregnancy (IPTp). To explore the impact of sextuple mutant haplotype infections on outcome measures after provision of IPTp with SP, we monitored birth outcomes in women followed up from before conception or from the first trimester until delivery. Women infected with sextuple haplotypes, in the early second trimester specifically, delivered newborns with a lower birth weight compared with women who did not have malaria during pregnancy (difference, −267 g; 95% confidence interval, −454 to −59; P = .01) and women infected with less SP-resistant haplotypes (−461 g; −877 to −44; P = .03). Thus, sextuple haplotype infections seem to affect the effectiveness of SP for IPTp and directly affect birth outcome by lowering birth weight. Close monitoring and targeted malaria control during early pregnancy is therefore crucial to improving birth outcomes.

Gestational diabetes mellitus (GDM) is associated with poor pregnancy outcomes and increased long-term risk of metabolic diseases for both mother and child. In Tanzania, GDM prevalence increased from 0% in 1991 to 19.5% in 2016. Anaemia has been proposed to precipitate the pathogenesis of GDM. We aimed to examine the prevalence of GDM in a rural area of Tanzania with a high prevalence of anaemia and to examine a potential association between haemoglobin concentration and blood glucose during pregnancy. The participants were included in a population-based preconception, pregnancy and birth cohort study. In total, 538 women were followed during pregnancy and scheduled for an oral glucose tolerance test (OGTT) at week 32&ndash, 34 of gestation. Gestational diabetes mellitus was diagnosed according to the WHO 2013 guidelines. Out of 392 women screened, 39% (95% CI: 34.2&ndash, 44.1) had GDM, the majority of whom (94.1%) were diagnosed based solely on the fasting blood sample from the OGTT. No associations were observed between haemoglobin or ferritin and glucose measurements during pregnancy. A very high prevalence of GDM was found in rural Tanzania. In view of the laborious, costly and inconvenient OGTT, alternative methods such as fasting blood glucose should be considered when screening for GDM in low- and middle-income countries.

Treating malaria in HIV-coinfected individuals should consider potential drug-drug interactions. Artemether-lumefantrine is the most widely recommended treatment for uncomplicated malaria globally. Lumefantrine is metabolized by CYP3A4, an enzyme that commonly used antiretrovirals often induce or inhibit. A population pharmacokinetic meta-analysis was conducted using individual participant data from 10 studies with 6,100 lumefantrine concentrations from 793 nonpregnant adult participants (41% HIV-malaria-coinfected, 36% malaria-infected, 20% HIV-infected, and 3% healthy volunteers)., Treating malaria in HIV-coinfected individuals should consider potential drug-drug interactions. Artemether-lumefantrine is the most widely recommended treatment for uncomplicated malaria globally. Lumefantrine is metabolized by CYP3A4, an enzyme that commonly used antiretrovirals often induce or inhibit. A population pharmacokinetic meta-analysis was conducted using individual participant data from 10 studies with 6,100 lumefantrine concentrations from 793 nonpregnant adult participants (41% HIV-malaria-coinfected, 36% malaria-infected, 20% HIV-infected, and 3% healthy volunteers). Lumefantrine exposure increased 3.4-fold with coadministration of lopinavir-ritonavir-based antiretroviral therapy (ART), while it decreased by 47% with efavirenz-based ART and by 59% in the patients with rifampin-based antituberculosis treatment. Nevirapine- or dolutegravir-based ART and malaria or HIV infection were not associated with significant effects. Monte Carlo simulations showed that those on concomitant efavirenz or rifampin have 49% and 80% probability of day 7 concentrations

Gestational diabetes mellitus (GDM) is associated with a range of adverse pregnancy outcomes as well as increased risk of future type 2 diabetes and cardiovascular disease. In India, 10%&ndash, 35% of pregnant women develop GDM. In this study, we investigated women&rsquo, s experiences with the dietary and pharmaceutical treatment for GDM in rural and urban Tamil Nadu, India. Semi-structured interviews were conducted with 19 women diagnosed with GDM. Data were analyzed using qualitative content analysis. Three overall aspects were discovered with several sub-aspects characterizing women&rsquo, s experiences: emotional challenges (fear and apprehension for the baby&rsquo, health and struggling to accept a treatment seen as counterintuitive to being safe and healthy), interpersonal challenges (managing treatment in the near social relations and social support, and coordinating treatment with work and social life), and health system-related challenges (availability and cost of treatment, interaction with health care providers). Some aspects acted as barriers. However, social support and positive, high-quality interactions with health care providers could mitigate some of these barriers and facilitate the treatment process. Greater efforts at awareness creation in the social environment and systemic adjustments in care delivery targeting the individual, family, community and health system levels are needed in order to ensure that women with GDM have the opportunity to access treatment and are enabled and motivated to follow it as well.

As strategies targeting undernutrition and infections become increasingly successful in low- and middle-income countries (LMICs), a second challenge has appeared, namely premature onset of non-communicable diseases (NCDs). In LMICs, NCDs are often related to exposure to undernutrition and infections. As NCDs strike societies and individuals with impaired resistance or a deficient health (care) state, why not label such diseases ‘opportunistic’, in analogy with opportunistic infections attacking individuals with HIV? We propose the concept of opportunistic NCDs, hoping that fighting against infections, and for better maternal and child health, is becoming acknowledged as essential for the early prevention of NCDs.

Antibiotic resistance, associated with inappropriate drug use, is a global public health threat. The pharmaceutical sectors in developing countries are poorly regulated leading to antibiotic sales and use without a prescription. The study documents the treatment of acute illnesses in households and the antibiotic dispensing practices of medicine sales outlets in Eastern region, Ghana.Twice-weekly illness recall visits were made to 12 households in three rural communities over eight consecutive weeks. Detailed fieldnotes were taken and analysed using a thematic approach. Quantitative counts of health events and treatment were also conducted. Dispensing practices were systematically observed and documented in three rural and three urban medicine outlets for analysis.Fever, abdominal, and respiratory symptoms were the most common causes of ill-health in the 12 households. Most (65%) medicine-use events involved self-treatment with pharmaceuticals; 40% of medicine-use events involved antibiotics, often without a prescription. Although the number of antibiotic transactions without prescription in rural medicine outlets (n = 139, 27.4%) was statistically significantly more than in urban pharmacies (n = 140, 13.5%); z = 6.7, p .0001), the volume of antibiotics sold in pharmacies was higher. Penicillins were the most commonly dispensed antibiotics constituting 30% of antibiotic sales in urban medicine outlets and 46% in rural ones. The lack of controls in the dispensing of antibiotics, community knowledge and use of antibiotics in ways inconsistent with biomedical recommendations, poverty and perceived barriers to formal healthcare were factors that influenced the inappropriate use of antibiotics.Self-medication, including antibiotic self-prescription, constitutes an integral part of healthcare in the study settings and the qualitative data provides a contextual understanding of over-the-counter antibiotic acquisition and use. Inappropriate antibiotic use is apparent in the study settings. Stricter regulation of the pharmaceutical sector, training of dispensers and evidence-based treatment guidelines, and public education are potential interventions.

Aims An estimated 87.6% of hyperglycaemia in pregnancy cases are in low and middle income countries (LMICs). The aim of this study is to review the evidence on barriers and facilitators to programmes and services addressing hyperglycaemia in pregnancy in LMICs. Methods A systematic review and narrative synthesis was conducted based on searches in PubMed. A total of 23 qualitative and quantitative studies were included. Results Barriers and facilitators exist at the health system level, individual level and social and societal levels and are often interacting. At the health system level they relate to capacity in terms of human and material resources; availability of feasible and appropriate guidelines; organisational management and referral pathways. Individual level barriers and facilitators include knowledge; risk perception; illness beliefs; financial condition; work obligations; concerns for the baby and hardship associated with services. At the social and societal level important factors are: perceptions and norms related to women’s roles, mobility and health; the knowledge and support of women’s social network; and structural aspects. Conclusions Numerous factors influence programmes and services addressing hyperglycaemia in pregnancy in LMICs. Thus, several components are needed to ensure detection, treatment and follow-up of women with hyperglycaemia in pregnancy.

Objective: To evaluate effect of locally tailored labour management guidelines (PartoMa guidelines) on intrahospital stillbirths and birth asphyxia. Design: Quasi-experimental pre-post study investigating the causal pathway through changes in clinical practice. Setting: Tanzanian low-resource referral hospital, Mnazi Mmoja Hospital. Population: Facility deliveries during baseline (1 October 2014 until 31 January 2015) and the 9th to 12th intervention month (1 October 2014 until 31 January 2015). Methods: Birth outcome was extracted from all cases of labouring women during baseline (n = 3690) and intervention months (n = 3087). Background characteristics and quality of care were assessed in quasi-randomly selected subgroups (n = 283 and n = 264, respectively). Main outcome measures: Stillbirths and neonates with 5-minute Apgar score ≤5. Results: Stillbirth rate fell from 59 to 39 per 1000 total births (RR 0.66, 95% CI 0.53–0.82), and subanalyses suggest that this was primarily due to reduction in intrahospital stillbirths. Apgar scores between 1 and 5 fell from 52 to 28 per 1000 live births (RR 0.53, 95% CI 0.41–0.69). Median time from last fetal heart assessment till delivery (or fetal death diagnosis) fell from 120 minutes (IQR 60–240) to 74 minutes (IQR 30-130) (Mann–Whitney test for difference, P < 0.01). Oxytocin augmentation declined from 22% to 12% (RR 0.54, 95% CI 0.37–0.81) and timely use improved. Conclusion: Although low human resources and substandard care remain major challenges, PartoMa guidelines were associated with improvements in care, leading to reductions in stillbirths and birth asphyxia. Findings furthermore emphasise the central role of improved fetal surveillance and restricted intrapartum oxytocin use in safety at birth. Tweetable abstract: #PartoMa guidelines aided in reducing stillbirths and birth asphyxia at a Tanzanian low-resource hospital. Plain Language Summary: PartoMa guidelines help birth attendants in Tanzania to save lives Every year, 3 million babies die on the day of birth. The vast majority of these deaths occur in the poorest countries. If their mothers had received better care during birth, most babies would have survived. At Mnazi Mmoja Hospital, an East African referral hospital, the PartoMa study shows that use of locally developed guidelines helps birth attendants to deliver better quality of care, which has led to improved survival at birth. At the hospital studied, resources are scarce. Each birth attendant assists four to six birthing women simultaneously, and many have less than 1 year of professional experience. International guidelines are available, but they are often unachievable and seldom applied. The PartoMa guidelines were developed in close collaboration with the birth attendants and approved by seven international experts. The result is an 8-page pocket booklet providing locally achievable and simple decision support for care during birth. Use of the PartoMa guidelines began in February 2015. As the staff group frequently changes, quarterly seminars are conducted where birth attendants are welcomed after working hours to learn about the guidelines. The guidelines have been positively received, and seminar attendance remains high. Use of the PartoMa guidelines is associated with: A decrease by one-third in stillbirths (59 to 39 per 1000 total births) A nearly halving in the number of babies born in immediate poor medical condition (52 to 28 per 1000 live births) The results presented here derive from a comparison of births before using the PartoMa guidelines and during the 9th–12th month of use. Such a ‘before-after’ study cannot exclude the possibility of other causes of better survival at birth. However, the improved survival is consistent with improved care during birth, which is in line with the PartoMa guidelines.

Aims: A number of aspects of the health status of migrants who return to their country of origin have been explored in the literature; however, a more general description of the incidence of disease and demographic characteristics is lacking. The aim of this research was to contribute such a description. Methods: A nationwide cohort study was conducted of 114,331 migrants who obtained residence in Denmark between 1 January 1993 and 31 December 2010. Demographic characteristics and ten disease groups were included as explanatory variables and hazards ratios for the association between return migration and disease incidence, as well as demographic characteristics, were estimated using Cox regressions. Results: The tendency to return-migrate when ill was not the same among younger and elderly migrants; migrants

Background In 2007, universal screening for gestational diabetes mellitus (GDM) was introduced in Tamil Nadu, India. To identify factors hindering or facilitating timely initiation and completion of the GDM screening and diagnosis process, our study investigated how pregnant women in rural and urban Tamil Nadu access and navigate different GDM related health services. Methods The study was carried out in two settings: an urban private diabetes centre and a rural government primary health centre. Observations of the process of screening and diagnosis at the health centres as well as semi-structured interviews with 30 pregnant women and nine health care providers were conducted. Data was analysed using qualitative content analysis. Results There were significant differences in the process of GDM screening and diagnosis in the urban and rural settings. Several factors hindering or facilitating timely initiation and completion of the process were identified. Timely attendance required awareness, motivation and opportunity to attend. Women had to attend the health centre at the right time and sometimes at the right gestational age to initiate the test, wait to complete the test and obtain the test report in time to initiate further action. All these steps and requirements were influenced by factors within and outside the health system such as getting right information from health care providers, clinic timings, characteristics of the test, availability of transport, social network and support, and social norms and cultural practices. Conclusions Minimising and aligning complex stepwise processes of prenatal care and GDM screening delivery and attention to the factors influencing it are important for further improving and expanding GDM screening and related services, not only in Tamil Nadu but in other similar low and middle income settings. This study stresses the importance of guidelines and diagnostic criteria which are simple and feasible on the ground. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1429-y) contains supplementary material, which is available to authorized users.

Aim To compare HbA1c and fasting plasma glucose assessment, with the 2-h oral glucose tolerance test as reference, in screening for diabetes in people with turberculosis. Methods Individuals (N=268) with newly diagnosed smear-positive tuberculosis were screened for diabetes at a tertiary hospital in Lahore, Pakistan. Diabetes diagnosis was based on WHO criteria: thresholds were ≥ 48 mmol/mol (≥6.5%) for HbA1c and ≥7.0mmol/l for fasting plasma glucose. Results The proportion of participants diagnosed with diabetes was 4.9% (n =13) by oral glucose tolerance test, while 11.9% (n =32) and 14.6% (n =39) were diagnosed with diabetes using HbA1c and fasting plasma glucose criteria, respectively. The area under the receiver-operating characteristic curve was 0.79 (95% CI 0.64 to 0.94) for HbA1c and 0.61 (95% CI 0.50 to 0.73) for fasting plasma glucose, with a borderline significant difference between the two tests (P=0.07). Conclusions HbA1c and fasting plasma glucose performed equally in terms of diagnosing new diabetes cases in individuals with tuberculosis, but the proportion of participants falsely classified as positive was higher for fasting plasma glucose. This may be explained by acute blood glucose fluctuations when using fasting plasma glucose. HbA1c may be a more reliable test in individuals with transient hyperglycaemia. This article is protected by copyright. All rights reserved.

Background:The success of prevention of mother-to-child transmission (PMTCT) programmes depends on retention of mothers throughout the PMTCT cascade. Methods:In a clinical trial of short-course combination antiretroviral therapy (cART) for PMTCT in Tanzania, senior nurses were employed to reduce the substantial loss-to-follow up (LTFU) rate. Results:Following intervention, the relative risk (RR) of receiving a CD4 count result and antiretroviral therapy was 1.16 (95% confidence interval [CI], 1.05 to 1.27), the RR of delivery at clinic was 2.51 (95% CI, 2.06 to 3.06), the RR for reporting for follow-up at 6 to 8 weeks postpartum was 4.63 (95% CI, 3.41 to 6.27), and the RR for being retained until 9 months postpartum was 28.19 (95% CI, 11.81 to 67.28). No significant impact on transmission was found. Conclusion:Significantly higher retention was found after senior nurses were employed. No impact on transmission was found. Relatively low transmission was found in both study arms.

Background and Aims: The prevalence of gestational diabetes mellitus (GDM) is increasing world-wide and it complicates around 1-10% of all pregnancies. GDM is associated with increased risk of long-term metabolic health consequences for both mother and child. In Tanzania, GDM prevalence increased from 0% in 1991 to 19.5% in 2016. Furthermore, the prevalence seems to be dependent on the living conditions, thus an overall GDM prevalence of 5.9% was found in urban areas and 1.0% in rural areas in Tanzania. We aimed to examine the prevalence of GDM in a rural district of North-Eastern Tanzania based upon an oral glucose tolerance test (OGTT) with subsequent fasting blood samples. Methods: The participants were included in a large population-based pre-pregnancy study named ”FOETALforNCD - Foetal Exposure and Epidemiological Transition: The Role of Anaemia in Early Life for Non-Communicable Diseases in Later Life." In total, 538 women were included in the pregnancy study; hereof 403 women were screened with an OGTT at week 32-34 of gestation, after 12 hours of fasting. GDM was diagnosed according to the WHO 2013 guidelines. Results: The OGTT results showed that 153 women had GDM, i.e., a prevalence of 39.0%. The majority (94.1%) were diagnosed based on the fasting blood sample. When examine the blood samples from the follow-up of the 153 women diagnosed with GDM, 41 had a confirmed GDM diagnosis (39 had repeated fasting blood sample and 2 had a repeated OGTT. In the remaining 112 women. GDM could not be validated. 40 women had repeated fasting blood samples, 43 had random blood samples, 3 had a repeated OGTT and 26 had no further blood samples taken. Conclusion: A very high prevalence of GDM was found in this part of Tanzania. In view of the laborious, costly and patient unfriendly OGTT, in low and middle-income countries alternative methods should be considered to be used to diagnose GDM. Disclosure L. Grunnet: None. L. Hjort: None. B.B. Nielsen: None. D.T. Minja: None. O.A. Msemo: None. J.P. Lusingu: None. R.B. Prasad: None. L. Groop: None. T.G. Theander: None. C. Schmiegelow: None. I.C. Bygbjerg: None. D.L. Christensen: None. Funding Danish Council for Strategic Research (1309-00003B)

PurposeLow-income and middle-income countries such as Tanzania experience a high prevalence of non-communicable diseases (NCDs), including anaemia. Studying if and how anaemia affects growth, placenta development, epigenetic patterns and newborns’ risk of NCDs may provide approaches to prevent NCDs.ParticipantsThe FOETALforNCD (FOetal Exposure and Epidemiological Transitions: the role of Anaemia in early Life for Non-Communicable Diseases in later life) Study is a population-based preconception, pregnancy and birth cohort study (n=1415, n=538, n=427, respectively), conducted in a rural region of North-East Tanzania. All participants were recruited prior to conception or early in pregnancy and followed throughout pregnancy as well as at birth. Data collection included: maternal blood, screening for NCDs and malaria, ultrasound in each trimester, neonatal anthropometry at birth and at 1 month of age, cord blood, placental and cord biopsies for stereology and epigenetic analyses.Findings to dateAt preconception, the average age, body mass index and blood pressure of the women were 28 years, 23 kg/m2 and 117/75 mm Hg, respectively. In total, 458 (36.7%) women had anaemia (haemoglobin Hb Future plansThe project will provide new knowledge on how health, even before conception, might modify the risk of developing NCDs and how to promote better health during pregnancy. The present project ended data collection 1 month after giving birth, but follow-up is continuing through regular monitoring of growth and development and health events according to the National Road Map Strategic Plan in Tanzania. This data will link fetal adverse event to childhood development, and depending on further grant allocation, through a life course follow-up.

Maternal anaemia in early pregnancy is associated with poor pregnancy outcomes. Furthermore, preconceptional health can influence the health during pregnancy. The aim of this study was to investigate which preconceptional factors were associated with haemoglobin (Hb) concentration in early pregnancy.In Tanzania, 226 women were followed at preconception and during early pregnancy. Red blood cell (RBC) morphology, serum micronutrient concentration, demographic characteristics and health status were assessed in preconception and in early pregnancy. The association between preconceptional factors and Hb concentration in early pregnancy was investigated using simple and multiple linear regression analyses stratified by preconceptional anaemia status.Mean Hb was 123 and 119 g/l before conception and during early pregnancy (median gestational age 53 days) respectively. Preconceptional mid-upper arm circumference (MUAC) (adjusted coefficient (AC) 0.35 95% CI 0.9-0.61) and preconceptional Hb concentration (AC 0.45 95% CI 0.36-0.54) were positively associated with early pregnancy Hb concentration, whereas preconceptional microcytic hypochromic RBC morphology (AC -6.00 95% CI -9.56 to -2.44) was negatively associated with early pregnancy Hb concentration. In addition, treatment of preconceptional malaria was positively associated with early pregnancy Hb concentration (AC 6.45 95% CI 0.74-12.2) among women with preconceptional anaemia. In contrast, among preconceptional non-anaemic women, only preconceptional Hb concentration and medium socio-economic status was positively associated with early pregnancy Hb concentration.Mid-upper arm circumference (MUAC) and Hb measurements in preconception can help to detect women at increased risk of low Hb concentration in early pregnancy.L'anémie maternelle en début de grossesse est associée à de mauvais résultats de grossesse. En outre, la santé préconceptionnelle peut influer sur la santé pendant la grossesse. Le but de cette étude était d'investiguer les facteurs préconceptionnels associés à la concentration d'hémoglobine (Hb) en début de grossesse. MÉTHODES: En Tanzanie, 226 femmes ont été suivies avant la conception et durant le début de la grossesse. La morphologie des globules rouges (GR), la concentration sérique en micronutriments, les caractéristiques démographiques et l’état de santé ont été évalués avant la conception et durant le début de la grossesse. L'association entre les facteurs préconceptionnels et la concentration d'Hb au début de la grossesse a été investiguée en utilisant des analyses de régression linéaire simples et multiples stratifiées selon le statut d'anémie préconceptionnelle. RÉSULTATS: Les concentrations moyennes d'Hb étaient respectivement de 123 g/L et de 119 g/L avant la conception et en début de grossesse (âge gestationnel médian: 53 jours). Le périmètre brachial (PB) préconceptionnel (coefficient ajusté (AC): 0.35; IC 95%: 0.9 à 0.61) et la concentration préconceptionnelle d'Hb (AC: 0.45; IC 95%: 0.36 à 0.54) étaient positivement associés à la concentration d'Hb au début de la grossesse, alors que la morphologie hypochrome microcytaire des GR préconceptionnelle (AC: −6.00; IC 95%: −9.56 à −2.44) était négativement associée à la concentration d'Hb en début de grossesse. De plus, le traitement du paludisme préconceptionnel était positivement associé à la concentration d'Hb au début de la grossesse (AC: 6.45; IC 95%: 0.74 à 12.2) chez les femmes souffrant d'anémie préconceptionnelle. En revanche, chez les femmes non anémiques en préconception, seule la concentration d'Hb préconceptionnelle et le statut socioéconomique moyen présentaient une association positive avec la concentration d'Hb en début de grossesse.Les mesures du PB et de la concentration d'Hb avant la conception peuvent aider à détecter les femmes à risque accru de faible concentration d’HB en début de grossesse.

Objective To estimate the effect of locally tailored clinical guidelines on intrapartum care and perinatal outcomes among women with severe hypertensive disorders in pregnancy (sHDP). Methods A pre–post study at Zanzibar's low‐resource Mnazi Mmoja Hospital was conducted. All labouring women with sHDP were included at baseline (October 2014 to January 2015) and at 9–12 months after implementation of the ongoing intervention (October 2015 to January 2016). Background characteristics, clinical practice, and delivery outcomes were assessed by criterion‐based case file reviews. Results Overall, 188 of 2761 (6.8%) women had sHDP at baseline, and 196 of 2398 (8.2%) did so during the intervention months. The median time between last blood pressure recording and delivery decreased during the intervention compared with baseline (P=0.015). Among women with severe hypertension, antihypertensive treatment increased during the intervention compared with baseline (relative risk [RR] 1.37, 95% confidence interval [CI] 1.14–1.66). Among the neonates delivered (birthweight ≥1000 g), stillbirths decreased (RR 0.56, 95% CI 0.35–0.90) and Apgar scores of seven or more increased during the intervention compared with baseline (RR 1.17, 95% CI 1.03–1.33). Conclusion Although health system strengthening remains crucial, locally tailored clinical guidelines seemed to help work‐overloaded birth attendants at a low‐resource hospital to improve care for women with sHDP. ClinicalTrials.org NCT02318420., Among women with severe hypertensive disorders at Zanzibar's referral hospital, locally tailored intrapartum guidelines were associated with care improvements and 44% risk reduction of stillbirth.

Publisher's version (útgefin grein), Background: The Ebola epidemic in West Africa caused global fear and stirred up worldwide preparedness activities in countries sharing borders with those affected, and in geographically far-away countries such as Iceland. Objective: To describe and analyse Ebola preparedness activities within the Icelandic healthcare system, and to explore the perspectives and experiences of managers and frontline health workers. Methods: A qualitative case study, based on semi-structured interviews with 21 staff members in the national Ebola Treatment Team, Emergency Room at Landspitali University Hospital, and managers of the response team. Results: Contextual factors such as culture and demography influenced preparedness, and contributed to the positive state of mind of participants, and ingenuity in using available resources for preparedness. While participants believed they were ready to take on the task of Ebola, they also had doubts about the chances of Ebola ever reaching Iceland. Yet, factors such as fear of Ebola and the perceived stigma associated with caring for a potentially infected Ebola patient, influenced the preparation process and resulted in plans for specific precautions by staff to secure the safety of their families. There were also concerns about the teamwork and lack of commitment by some during training. Being a ‘tiny’ nation was seen as both an asset and a weakness in the preparation process. Honest information sharing and scenario-based training contributed to increased confidence amongst participants in the response plans. Conclusions: Communication and training were important for preparedness of health staff in Iceland, in order to receive, admit, and treat a patient suspected of having Ebola, while doubts prevailed on staff capacity to properly do so. For optimal preparedness, likely scenarios for future global security health threats need to be repeatedly enacted, and areas plagued by poverty and fragile healthcare systems require global support., We are grateful to participating institutions for giving permission to conduct the study, but not the least, to the participants who contributed with their time and experience.

Background Small-for-gestational-age (SGA) is associated with increased neonatal mortality and morbidity. In low and middle income countries an accurate gestational age is often not known, making the identification of SGA newborns difficult. Measuring foot length, chest circumference and mid upper arm circumference (MUAC) of the newborn have previously been shown to be reasonable methods for detecting low birth weight (

Objectives People with diabetes are at high risk of polypharmacy owing to complex treatment of diabetes and comorbidities. Polypharmacy is associated with increased risk of adverse reactions and decreased compliance. Therefore, the objectives of this study were to assess polypharmacy in people with type 2 diabetes (T2D) and associated diabetes-related factors in rural areas in Vietnam. Method People with T2D (n = 806) who had received treatment for diabetes at a district hospital were invited to participate in a questionnaire-based cross-sectional survey. Polypharmacy was defined as ≥5 types of medicine and assessed as a) prescription medicine and non-prescription/over the counter (OTC) medicine and b) prescription medicine and non-prescription/OTC, herbal and traditional medicine, and dietary supplement. Multiple logistic regression was used to investigate the association between polypharmacy and diabetes specific factors: duration, comorbidities and diabetes-related distress. Results Of the people with T2D, 7.8% had a medicine use corresponding to polypharmacy (prescription medicine and non-prescription/OTC), and 40.8% when herbal and traditional medicine, and dietary supplement were included. Mean number of medicine intake (all types of medicines and supplements) were 3.8±1.5. The odd ratios (ORs) of polypharmacy (medicine and supplements) increased with diabetes duration (5 years OR = 1.74; 95%CI: 1.14–2.64 as compared to ≤1-year duration of diabetes), number of comorbidities (1–2 comorbidities: OR = 2.0; 95%CI: 1.18–3.42; ≥3 comorbidities: OR = 2.63;95%CI: 1.50–4.61 as compared to no comorbidities), and suffering from diabetes-related distress (OR = 1.49; 95%CI: 1.11–2.01) as compared to those without distress. Conclusions In rural northern Vietnam, persons with longer duration of T2D, higher number of comorbidities and diabetes-related stress have higher odds of having a medicine use corresponding to polypharmacy. A high proportion of people with T2D supplement their prescription, non-prescription/OTC medicine with herbal and traditional medicine and dietary supplements.

Objective Studies of diabetes in migrant populations have shown a higher prevalence compared to their respective countries of origin and to people natively born in the host country, but there is little population-based data on diabetes incidence and mortality in migrant populations. The aim of the current study was (1) to describe the incidence rates and prevalence of diabetes among first generation migrants in Denmark compared to the Danish background population, and (2) to compare standardised mortality rates (SMRs) for individuals with and without diabetes according to country of origin. Research design and methods Information was obtained from linkage of the National Diabetes Register with mortality statistics and information from the Central Personal Register on country of origin. Age- and sex-specific estimates of prevalence, incidence rates, mortality rates and SMRs relative to the part of the population without diabetes were calculated based on follow up of the entire Danish population. Results Compared with native born Danes, the incidence of diabetes was about 2.5 times higher among migrants from Africa, Asia, and the Middle East, and these migrant groups also showed significantly higher prevalence. The standardised mortality rates (SMR) were higher particularly above 50 years of age among most migrant groups compared with native born Danes, and with a higher annual increase. Conclusions The highest diabetes incidence rates and prevalence estimates were observed among migrants from Africa, Asia, and the Middle East, and the annual increase in SMRs was higher in these groups compared to native born Danes. © 2016 Elsevier Ireland Ltd

Background To study determinants of stillbirths as indicators of quality of care during labour in an East African low resource referral hospital. Methods A criterion-based unmatched unblinded case-control study of singleton stillbirths with birthweight ≥2000 g (n = 139), compared to controls with birthweight ≥2000 g and Apgar score ≥7 (n = 249). Results The overall facility-based stillbirth rate was 59 per 1000 total births, of which 25 % was not reported in the hospital’s registers. The majority of singletons had birthweight ≥2000 g (n = 139; 79 %), and foetal heart rate was present on admission in 72 (52 %) of these (intra-hospital stillbirths). Overall, poor quality of care during labour was the prevailing determinant of 71 (99 %) intra-hospital stillbirths, and median time from last foetal heart assessment till diagnosis of foetal death or delivery was 210 min. (interquartile range: 75–315 min.). Of intra-hospital stillbirths, 26 (36 %) received oxytocin augmentation (23 % among controls; odds ratio (OR) 1.86, 95 % confidential interval (CI) 1.06–3.27); 15 (58 %) on doubtful indication where either labour progress was normal or less dangerous interventions could have been effective, e.g. rupture of membranes. Substandard management of prolonged labour frequently led to unnecessary caesarean sections. The caesarean section rate among all stillbirths was 26 % (11 % among controls; OR 2.94, 95 % CI 1.68–5.14), and vacuum extraction was hardly ever done. Of women experiencing stillbirth, 27 (19 %) had severe hypertensive disorders (4 % among controls; OR 5.76, 95 % CI 2.70–12.31), but 18 (67 %) of these did not receive antihypertensives. An additional 33 (24 %) did not have blood pressure recorded during active labour. When compared to controls, stillbirths were characterized by longer admissions during labour. However, substandard care was prevalent in both cases and controls and caused potential risks for the entire population. Notably, women with foetal death on admission were in the biggest danger of neglect. Conclusions Intrapartum management of women experiencing stillbirth was a simple yet strong indicator of quality of care. Substandard care led to perinatal as well as maternal risks, which furthermore were related to unnecessary complex, time consuming, and costly interventions. Improvement of obstetric care is warranted to end preventable birth-related deaths and disabilities. Trial registration This is the baseline analysis of the PartoMa trial, which is registered on ClinicalTrials.org (NCT02318420, 4th November 2014). Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1142-2) contains supplementary material, which is available to authorized users.

BACKGROUND Syphilis testing conventionally relies on a combination of non-treponemal and treponemal tests. The primary objective of this study was to describe the positive predictive value (PPV) of a screening algorithm in a combination of a treponemal rapid diagnostic test (RDT) and rapid plasma reagin (RPR) test at Komfo Anokye Teaching Hospital (KATH), Ghana. MATERIALS AND METHODS From February 2014 to January 2015, 5 mL of venous blood samples were taken from 16 016 blood donors and tested with a treponemal RDT; 5 mL of venous blood was taken from 526 consenting initial syphilis sero-reactive blood donors. These RDT reactive samples were confirmed with an algorithm, applying the Vitros(®) /Abbott-Architect(®) algorithm as gold standard. RESULTS A total of 478 of 526 RDT reactive donors were confirmed positive for syphilis, making a PPV of 90·9%. Of the 172 (32·7%) donors who were also RPR positive, 167 were confirmed, resulting in a PPV of 97·1%. The PPV of the combined RDT and RPR (suspected active syphilis) testing algorithm was highest among donors at an enhanced risk of syphilis, family/replacement donors (99·9%), and among voluntary donors above 25 years (98·6%). DISCUSSION Screening of blood donors by combining syphilis RDT and RPR with relatively good PPV may provide a reasonable technology for LMIC that has a limited capacity for testing and can contribute to the improvement of blood safety with a minimal loss of donors.

Interferon-gamma (IFN-γ) release assays (IGRAs) are used to detect cellular immune recognition of Mycobacterium tuberculosis. The chemokine IFN-γ-inducible protein 10 (IP-10) is an alternative diagnostic biomarker to IFN-γ. Several conditions interfere with IGRA test performance. We aimed to assess the possible influence of Plasmodium falciparum infection on the IGRA test QuantiFERON-TB GOLD® In-Tube (QFT) test and an in-house IP-10 release assay. In total, 241 Tanzanian adults were included; 184 patients with uncomplicated malaria (88 human immunodeficiency virus [HIV] coinfected) and 57 HIV-infected patients without malaria infection. Malaria was treated with artemether–lumefantrine (Coartem®). QFT testing was performed before initiation of malaria treatment and at days 7 and 42. In total, 172 patients completed follow-up. IFN-γ and IP-10 was measured in QFT supernatants. We found that during malaria infection IFN-γ and IP-10 levels in the unstimulated samples were elevated, mitogen responsiveness was impaired, and CD4 cell counts were decreased. These alterations reverted after malaria treatment. Concurrent malaria infection did not affect QFT test results, whereas there were more indeterminate IP-10 results during acute malaria infection. We suggest that IGRA and IP-10 release assay results of malaria patients should be interpreted with caution and that testing preferably should be postponed until after malaria treatment.

Background. Health professionals assign diabetes patients “homework” in that they give them instructions on how to manage diabetes, recognizing that most diabetes care takes place in the home setting. We studied how homework is practiced and whether knowledge and behavioral practices related to diabetes self-management diffuse from patients to their housemates. Method. This mixed-methods study combined quantitative data from a household survey including 90 rural Ugandan households (50% had a member with type 2 diabetes [T2D]) with qualitative data from health facilities and interviews with 10 patients with T2D. Focus for data collection was knowledge and practices related to diabetes homework. A generalized mixed model was used to analyze quantitative data, while content analysis was used for qualitative data analysis. Results. Patients with T2D generally understood the diabetes homework assignments given by health professionals and carried out their homework with support from housemates. Although adherence to recommended diet was variable, housemates were likely to eat a healthier diet than if no patient with T2D lived in the household. Knowledge related to diabetes homework diffused from the patients to housemates and beyond to neighbors and family living elsewhere. Knowledge about primary prevention of T2D was almost absent among health staff, patients, and relatives. Conclusions. Homework practices related to T2D improve diabetes-related knowledge and may facilitate healthy eating in nondiabetic housemates. These findings suggest that having a chronic disease in the household provides an opportunity to improve health in the entire household and address the lack of knowledge about prevention of T2D.

Background Pregnancy malaria has a negative impact on fetal outcome. It is uncertain whether infections in early pregnancy have a clinical impact by impeding the development of the placental vasculature. Methods Tanzanian women (n = 138) were closely monitored during pregnancy. Placentas collected at birth were investigated using stereology to establish the characteristics of placental villi and vessels. Placental vasculature measures were compared between women infected with malaria and controls. Results Compared with controls, placentas from women infected with malaria before a gestational age (GA) of 15 weeks had a decreased volume of transport villi (mean decrease [standard deviation], 12.45 [5.39] cm3; P = .02), an increased diffusion distance in diffusion vessels (mean increase, 3.33 [1.27] µm; P = .01), and a compensatory increase in diffusion vessel surface area (mean increase, 1.81 [0.74 m2]; P = .02). In women who had malaria before a GA of 15 weeks diffusion vessel surface area and transport vessel length distance were positive predictors for birth weight (multilinear regression: P = .007 and P = .055 for diffusion surface area and transport length, respectively) and GA at delivery (P = .005 and P = .04). Conclusions Malaria infection in early pregnancy impedes placental vascular development. The resulting phenotypic changes, which can be detected at delivery, are associated with birth weight and gestational length. Clinical Trials Registration NCT02191683.

Gaps exist between internationally derived clinical guidelines on care at the time of birth and realistic best practices in busy, low-resourced maternity units.In 2014-2018, we carried out the PartoMa study at Zanzibar's tertiary hospital, United Republic of Tanzania. Working with local birth attendants and external experts, we created easy-to-use and locally achievable clinical guidelines and associated in-house training to assist birth attendants in intrapartum care.Around 11 500 women gave birth annually in the hospital. Of the 35-40 birth attendants employed, each cared simultaneously for 3-6 women in labour. At baseline (1 October 2014 to 31 January 2015), there were 59 stillbirths per 1000 total births and 52 newborns with an Apgar score of 1-5 per 1000 live births. Externally derived clinical guidelines were available, but rarely used.Staff attendance at the repeated trainings was good, despite seminars being outside working hours and without additional remuneration. Many birth attendants appreciated the intervention and were motivated to improve care. Improvements were found in knowledge, partograph skills and quality of care. After 12 intervention months, stillbirths had decreased 34% to 39 per 1000 total births, while newborns with an Apgar score of 1-5 halved to 28 per 1000 live births.After 4 years, birth attendants still express high demand for the intervention. The development of international, regional and national clinical guidelines targeted at low-resource maternity units needs to be better attuned to input from end-users and the local conditions, and thereby easier to use effectively.Des écarts existent entre les directives cliniques internationales relatives aux soins au moment de la naissance et les meilleures pratiques réalistes dans les services de maternité très sollicités et à faibles ressources.En 2014-2018, nous avons réalisé l'étude PartoMa au sein de l'hôpital tertiaire de Zanzibar, en République-Unie de Tanzanie. Dans le cadre d'une collaboration avec des professionnels locaux de l'accouchement et des experts externes, nous avons créé des directives cliniques faciles à utiliser et applicables localement, et nous avons associé à ces directives une formation interne destinée à aider les professionnels de l'accouchement lors des soins pendant l'accouchement.Environ 11 500 femmes accouchent chaque année dans cet hôpital. Chacun des 35-40 professionnels de l'accouchement employés s'occupait simultanément de 3 à 6 femmes en travail. Au début de l'étude (du 1er octobre 2014 au 31 janvier 2015), on dénombrait 59 mortinaissances pour 1 000 naissances totales et 52 nouveaux nés avec un score d'Apgar de 1-5 pour 1 000 naissances vivantes. Des directives cliniques provenant de l'extérieur étaient disponibles, mais rarement utilisées.La participation du personnel aux différentes formations était bonne, alors que les séminaires étaient organisés en dehors des heures de travail et ne donnaient pas lieu à une rémunération supplémentaire. De nombreux professionnels de l'accouchement ont apprécié l'intervention et étaient désireux d'améliorer les soins apportés. Des améliorations ont été constatées concernant les connaissances, l'utilisation du partogramme et la qualité des soins. Après 12 mois d'intervention, le taux de mortinatalité avait diminué de 34%, passant à 39 mortinaissances pour 1 000 naissances totales, tandis que le nombre de nouveaux nés avec un score Apgar de 1-5 avait diminué de moitié, passant à 28 pour 1 000 naissances vivantes.Après 4 ans, les professionnels de l'accouchement étaient toujours nombreux à vouloir participer à l'intervention. Les avis des utilisateurs finaux et les conditions locales doivent être mieux pris en compte lors de l'élaboration de directives cliniques internationales, régionales et nationales destinées aux services de maternité à faibles ressources pour être plus faciles à utiliser de façon efficace.Existen lagunas entre las directrices clínicas internacionales sobre la atención durante el parto y las mejores prácticas realistas en las unidades de maternidad concurridas y con escasos recursos.Entre 2014 y 2018, se llevó a cabo el estudio PartoMa en el hospital de nivel terciario de Zanzíbar, República Unida de Tanzania. Con la ayuda de asistentes de partos locales y expertos externos, se elaboraron directrices clínicas fáciles de usar y factibles localmente y se impartió formación interna asociada para ayudar a los asistentes de partos en la atención durante el parto.Alrededor de 11 500 mujeres dan a luz anualmente en el hospital. De los 35 a 40 asistentes de partos empleados, cada uno se ocupó simultáneamente de 3 a 6 mujeres de parto. Al inicio (del 1 de octubre de 2014 al 31 de enero de 2015), había 59 mortinatos por cada 1000 nacimientos totales y 52 recién nacidos con una puntuación de Apgar de entre 1 y 5 por cada 1000 nacidos vivos. Se disponía de directrices clínicas derivadas de fuentes externas, pero rara vez se utilizaban.La asistencia del personal a los repetidos cursos de formación fue buena, a pesar de que los seminarios se celebraron fuera del horario laboral y sin remuneración adicional. Muchos asistentes de partos apreciaron la intervención y se sintieron motivados para mejorar la atención. Se observaron mejoras en los conocimientos, las habilidades de partografía y la calidad de la atención. Después de 12 meses de intervención, los mortinatos disminuyeron un 34 % a 39 por cada 1000 nacimientos totales, mientras que los recién nacidos con una puntuación de Apgar de entre 1 y 5 se redujeron a la mitad a 28 por cada 1000 nacidos vivos.Después de 4 años, los asistentes de partos todavía expresan una alta demanda de la intervención. La elaboración de directrices clínicas internacionales, regionales y nacionales dirigidas a las unidades de maternidad con escasos recursos debe estar mejor adaptada a las aportaciones de los usuarios finales y a las condiciones locales y, por tanto, ser más fácil de utilizar de manera eficaz.توجد فجوات بين المبادئ التوجيهية السريرية الدولية الخاصة الرعاية في وقت الولادة، وأفضل الممارسات الواقعية في وحدات الأمومة المزدحمة منخفضة الموارد.قمنا في الفترة من 2014 إلى 2018، بإجراء دراسة PartoMa في مستشفى زنزبار فوق الثانوي، بجمهورية تنزانيا المتحدة. بناء على التعاون مع قابلات الولادة المحليات والخبراء الخارجيين، قمنا بوضع مبادئ توجيهية تتميز بسهولة الاستخدام وقابلة التحقيق المحلي، كما أضفنا التدريب الداخلي لمساعدة القابلات في الرعاية أثناء الولادة.国际上制定的分娩护理临床指南与在繁忙、资源匮乏的妇产科医院实现最佳实践间存在差距。.2014–2018 年间，我们在坦桑尼亚联合共和国桑给巴尔三级医院进行了 PartoMa 研究。我们与当地接生人员和外部专家合作制定了易于使用、在当地可实行的临床指南以及相关的内部培训，以协助助产士进行分娩护理。.每年约有 11500 名妇女在这家医院分娩。在受雇的 35 至 40 名助产士中，每名助产士需同时照护 3 至 6 名产妇。在基准值上（2014 年 10 月 1 日至 2015 年 1 月 31 日），每 1000 名新生儿中有 59 名死胎，每 1000 名活产儿中有 52 名新生儿 Apgar 评分在 1–5 分。虽然外部制定的临床指南切实可行，但却很少使用。.尽管研讨会是在工作之余举办，并无额外报酬，但员工再培训的出勤率依然很高。许多助产士对此干预方式予以理解，并积极改善护理。知识水平、分娩技能和护理质量方面均有所改善。经过 12 个月的干预后，死胎率下降了 34%，每 1000 名新生儿中只有 39 名死胎，每 1000 名活产儿中仅有 28 名新生儿 Apgar 评分在 1–5 分，减少了近一半。.4 年过去了，助产士对干预的要求依然很高。制定针对资源匮乏的妇产科医院的国际、区域和国家临床指南需要更好地协调最终用户的投入和当地条件之间的关系，因而更容易有效使用。.Существует разрыв между международными клиническими рекомендациями по уходу за матерью и ребенком в родах и практическим опытом, реализуемым в перегруженных и не располагающих достаточными ресурсами родильных отделениях.В 2014–2018 годах авторы провели исследование PartoMa в специализированной больнице Занзибара (Объединенная Республика Танзания). Работая с местными акушерами и сторонними специалистами, авторы создали простые в использовании и реально достижимые на местах клинические рекомендации и соответствующий учебный курс для акушеров по медицинскому обслуживанию в родах.Ежегодно в больнице рожают около 11 500 женщин. Из работающих 35–40 акушеров на каждого специалиста приходится одновременно от 3 до 6 рожениц. В качестве базового показателя (по состоянию с 1 октября 2014 года по 31 января 2015 года) было зафиксировано 59 случаев мертворождения на 1000 родов и 52 новорожденных с оценкой 1–5 по шкале Апгар на 1000 живорожденных младенцев. Клинические рекомендации, разработанные сторонними организациями, были доступны, но редко применялись.Несмотря на то что семинары проводились в нерабочее время и не оплачивались дополнительно, сотрудники исправно посещали многократные курсы обучения. Многие акушеры приветствовали принимаемые меры и были заинтересованы в совершенствовании качества медицинской помощи. Было отмечено улучшение знаний, навыков использования партографа и качества оказываемой помощи. Спустя 12 месяцев после начала вмешательства количество мертворождений снизилось на 34% (до 39 случаев на 1000 рождений), а количество новорожденных с оценкой 1–5 по шкале Апгар уменьшилось вдвое (до 28 случаев на 1000 живорожденных младенцев).Спустя 4 года акушеры по-прежнему заинтересованы во вмешательстве в их сферу деятельности. При разработке международных, национальных и региональных клинических рекомендаций для родильных отделений, не располагающих достаточными ресурсами, следует более внимательно относиться к пожеланиям тех, кто будет этими рекомендациями пользоваться, и к местным условиям. В таком случае они будут использоваться более эффективно.

Background Although the recent decline of malaria burden in some African countries has been attributed to a scale-up of interventions, such as bed nets (insecticide-treated bed nets, ITNs/long-lasting insecticidal nets, LLINs), the contribution of other factors to these changes has not been rigorously assessed. This study assessed the trends of Plasmodium falciparum prevalence in Magoda (1992–2017) and Mpapayu (1998–2017) villages of Muheza district, North-eastern Tanzania, in relation to changes in the levels of different interventions and rainfall patterns. Methods Individuals aged 0–19 years were recruited in cross-sectional surveys to determine the prevalence of P. falciparum infections in relation to different malaria interventions deployed, particularly bed nets and anti-malarial drugs. Trends and patterns of rainfall in Muheza for 35 years (from 1981 to 2016) were assessed to determine changes in the amount and pattern of rainfall and their possible impacts on P. falciparum prevalence besides of those ascribed to interventions. Results High prevalence (84–54%) was reported between 1992 and 2000 in Magoda, and 1998 and 2000 in Mpapayu, but it declined sharply from 2001 to 2004 (from 52.0 to 25.0%), followed by a progressive decline between 2008 and 2012 (to ≤ 7% in both villages). However, the prevalence increased significantly from 2013 to 2016 reaching ≥ 20.0% in 2016 (both villages), but declined in the two villages to ≤ 13% in 2017. Overall and age specific P. falciparum prevalence decreased in both villages over the years but with a peak prevalence shifting from children aged 5–9 years to those aged 10–19 years from 2008 onwards. Bed net coverage increased from 98% in 2001 and was ≥ 85.0% in 2004 in both villages; followed by fluctuations with coverage ranging from 35.0 to ≤ 98% between 2008 and 2017. The 12-month weighted anomaly standardized precipitation index showed a marked rainfall deficit in 1990–1996 and 1999–2010 coinciding with declining prevalence and despite relatively high bed net coverage from 2000. From 1992, the risk of infection decreased steadily up to 2013 when the lowest risk was observed (RR = 0.07; 95% CI 0.06–0.08, P